Last updated 12/23/2022
These clinical recommendations were created by NORMUK to aid in the diagnosis and management of phimosis among medical professionals and health authorities.
These recommendations are the first of a set that will also include recommendations for the management of balanoposthitis and other conditions that may have an impact on the foreskin.
Normal Anatomy and Development
The prepuce, also known as the foreskin, provides an anatomical covering over the glans and is a vital, natural component of the penis. It is a unique junctional mucosa with specialized innervation that serves as erogenous tissue. The prepuce contains thousands of nerve endings, Meissner and Vater-Pacini corpuscles, and specialized sensory receptors such Merkel cell discs.
The sensory receptors of the preputial mucosa’s ridged band may be a component of the reflex’ afferent limb. In a newborn male infant, the prepuce has not fully developed. Foreskin re-tractability and separation from the glans happen at various ages.
There is no time limit for this, and full re-tractability frequently does not develop until well into adolescence. A prepubescent child’s non-retractable foreskin is not a sickness and doesn’t need to be treated.
Phimosis is not the inability of the foreskins function to retract throughout childhood. Innocent and temporary, ballooning during micturition is a typical component of development and doesn’t need to be treated. Scarring of the prepuce tip is considered to be true phimosis and is typically caused by Balanitis Xerotica Obliterans (BXO).
According to a recent report, there are 0.4 occurrences of pathological phimosis per 1000 boys annually, or 0.6% of males by the age of 15. In adulthood, the non-retractable foreskin may also be referred to as phimosis.
It is important to recognize and respect a child’s normal non-retractile foreskin. Patients and their parents should be warned against attempting a forced or early retraction of the foreskin and against using too much soap.
Following a diagnosis of phimosis, therapeutic options include full or partial circumcision, preputial plasty and manual stretching.
Topical corticosteroids like Hydrocortisone are also frequently used in conjunction. Surgery should only be done as a last option after trying more conservative therapy first. Below are descriptions of the various therapy choices.
According to several studies, topical prednisone can safely and successfully treat phimosis in 80–90% of patients. 2-3 times per day, the exterior and interior of the foreskin tip should be treated with betamethasone cream 0.05%. If the foreskin does not become retractile after 3 months, the treatment should be stopped as useless.
For the non-retractable foreskin of an adult or adolescent, several plastic repairs are possible. These include preputial plasty, which entails making a dorsal, longitudinal incision into the foreskin’s constriction band.
The Buck’s fascia is exposed by spreading the underlying tissue with artery forceps, and the incision is then stitched transversely with absorb-able sutures. The prepuce can be kept after this operation, which has lower morbidity rates than circumcision.
A child’s circumcision is traumatic, as it is with any surgery. It should only be used as a last option because it is practically irreversible. It has been thought that the only common absolute indication for circumcision is pathological phimosis brought on by BXO. However, BXO and Lichen Sclerosis Atrophicans are similar (LSA).
According to reports, circumcision is useless in either preventing or treating BXO. Topical corticosteroids, topical testosterone, and carbon dioxide laser therapy all work on BXO. One study demonstrates the efficacy of long-term antibiotic use, but it is unclear whether this is attributable to antimicrobial activity.
Cautions for Circumcision
Since circumcision is practically permanent, it should only be used as a last option. All of the following patient requirements must be satisfied before a circumcision can be done.
- Have a valid therapeutic justification for circumcision, after trying and failing with conservative treatment.
- Have an understanding of the consequences of circumcision and be willing to undergo the procedure.
- Have recognized that there is a 2% probability of significant problems following circumcision.
- Have a supportive friend or family member spend the night with them.
- Cold C and Taylor J. The Prepuce. BJU International, 1999;83: Suppl 1, 34-44
- Cold C and McGrath K. Anatomy and histology of the penile and clitoral prepuce in primates. In G Denniston et al (eds), Male and female circumcision: Medical, Legal and Ethical Considerations in Pediatric Practice (1999). NY Plenum.
- Taylor JR, Lockwood and Taylor AJ. The Prepuce: Specialised Mucosa of the Penis and its Loss to Circumcision. Brit J Urol 1996;77:291-295
- Gairdner DM, MRCP. The Fate of the Foreskin. BMJ. 1949;2:1433-1437
- Oster J, Further fate of the Foreskin. Arc Dis Child, 1968;43:200-36
- Rickwood AMK and Walker J. Is phimosis overdiagnosed and are too many circumcisions performed in consequence? An Royal Coll Surg Engl, 1989;71:275-7
- Rickwood AMK, Hemalatha V, Batcup G and Spitz L. Phimosis in boys. BJ Urol 1980;52:147-150
- Shankar KR and Rickwood AMK. The incidence of phimosis in boys. BJU International 1999;84:101-2
- Lang K. Eine konservative Therapie der Phimose. Monatsschr Kinderheilkd. 1986;134:824-5
- Meyrick Thomas RH, Ridley CM, Black MM. Clinical features and therapy of lichen sclerosus et atrophicus affecting males. Clin Exp Dermatol. 1987;12:126-128
- Fortier-Bealieu M, Thomine E, Mitrofanof P Laurent P, Heinet J. Lincehn sclero-atrophique preputial de l’enfant. Ann Pediatr (Paris).1990;3:673-676
- Jorgensen ET, Svensson A. The treatment of phimosis in boys with a potent topical steriod (clobetsol propinate 0.05%) cream. Acta Derm Verereol 1993;73:55-6
- Kikiros CS, Beasley SW, Woodward AA. The response of phimosis to local steriod application. Pediatr Surg Int 1993;8:329-32
- Wright JE. The treatment of phimosis with topical steriod. Aust NZ J Surg 1994;64:327-8
- Jorgensen ET, Svensson A. Phimosis hos pjkar kan behandlas med steriod salva (letter) Lakartidningen 1994;91:1291
- Golubovic Z, Milanovic D et al. The conservative treatment of phimosis in boys. Brit J Urol 1996;78:786-788
- Beauge M. Conservative Treatment of Primary Phimosis in Adolescents [Traitment Medical du Phimosis Congenital de L’Adolescent]. Saint Antione University, Paris VI, 1990-1991
- Dunn HP. Non-surgical management of phimosis. Aust NZ J Surg. 1989;59:963
- Diaz A, Kantor HI. Dorsal Slit. A circumcision alternative. Obstet Gynecol 1971;37:619-22
- Parkash S. Phimosis and it’s plastic correction. J Indian Med Assoc 1972;58:389-90
- Holmland DE. Dorsal incision of the prepuce and skin closure with Dexon in patients with phimosis. Scan J Urol Nephrol 1973;7:97-9
- Emmett AJ. Four V-flap repair of preputial stenosis (phimosis). Plast Reconstr Surg 1975;55:687-9
- Gil Barbosa M, Aquilera Gonzalez C, Alipaz A, Garcia Sanchez JL. La balanolisis como sustituto de la circumcision. Salud Publica Mex 1976;18:893-9
- Ohijimi T, Ohijimi H. Special surgical techniques for relief of phimosis. J Dermatol Surg Oncol 1981;7:326-30
- Emmett AJ. Z-plasty reconstruction for preputial stenosis- a surgical alternative to circumcision. Aust Paediatr J 1982;18:219-20
- Hoffman S. Metz P, Ebbehoj J. A new operation for phimosis: prepuce saving technique with multiple Y-V plasties. Br J Urol 1984;56:319-21
- Moro G, Gesmundo R, Bevilacqua A, Maiullari E, Gandini R. La circoncisione con postoplastica. Nota di tecnica operatoria. Minerva Chir 1988;43:893-4
- Wahlin N. “Triple incision plasty”. A convenient procedure for preputial relief. Scand J Urol Nephrol 1992;26(2):107-10.
- Cuckow PM, Rix G, Mouriquand PD. Preputial plasty: a good alternative to circumcision. J Pediatr Surg 1994;29:561-3
- de Castella H. Prepuceplasty: an alternative to circumcision. Ann R Coll Surg Engl 1994;76:257-8
- Leal MJ, Mendes J. A circuncisao ritual e correccao plastica da fomise. Acta Med port 1994;7:475-481
- Ohijim H, Ogata K, Ohijim T. A new method for the relief of adult phimosis. J Urol 1995;153:1607-9
- Rickwood AMK, Medical indications for circumcision. BJU Intl. 1999;83 Suppl 1: 45-51.
- Pasieczny TA. The treatment of balanitis xerotica obliterans with testosterone propinate ointment. Acta Derm Venereol. 1977;57(3):275-7
- Freeman C and Laymon CW. Archs Derm Syph 1941;44:547
- Laymon CW and Freeman C. Archs Derm Syph 1944;49:57
- Catteral RD and Oates JK. Br J Vener Dis. 1962;38:75
- Poynter JH, Levy J. Balanitis xerotica obliterans; effective treatment with topical and sublesional corticosteroids. Brit J Urol 1967 Aug 39(4);420-5.
- Pasieczny TA. The treatment of balanitis xerotica obliterans with testosterone propinate ointment. Acta Derm Venereol 1977;57 (3):275-7
- Ratz JL. Carbon dioxide laser treatment of balanitis xerotica obliterans. J Am Acad Dermatol 1984;10 (5 Pt 2):925-8
- Rosemberg SK. Carbon dioxide laser treatment of external genital lesions. Urology 1985;25(6):55-8
- Shelley WB, Shelley ED, Grunenwald MA, Anders TJ, Ramnath A. Long term antibiotic therapy for balanitis xerotica obliterans. J Am Acad Dermatol 1999 Jan;40(1):69-72
- Williams N, Kapila L. Complications of circumcision. Br J Surg 1993;80:1231-36
- John R J. A Myths surrounding circumcision. Forma Med port 1996;9:435-741
The intent of all NORMUK content is to provide knowledge for educational purposes only. It is not meant to be interpreted as medical or legal advice . Always speak with a physician before applying any recommendations seen on NORMUK, or anywhere else on the internet.
4 thoughts on “Clinical Guidelines for Phimosis”